331880742-5-17-2023-18-AS-CNWE-CRWSN8-20230517140106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880742
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:01:15 PM

Document Has Been Signed on 05/17/2023 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	A HOME 4 WAYNE, INC.		FACILITY NUMBER:	331880742
ADMINISTRATOR:	WATSON, PAMELA		FACILITY TYPE:	735
ADDRESS:	621 GROVESIDE DR		TELEPHONE:	(951) 219-2467
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92582
CAPACITY: 6		CENSUS: 4	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	James Willis, Caregiver		TIME COMPLETED:	02:10 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 5/17/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Daniel Tellez. LPA also met with Lead Caregiver, James Willis who was informed of the purpose of visit. At the time of visit there was 2 staff and 2 residents present. LPA toured the facility inside and out with James.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked box located in staff room, available only to authorized individuals. Trash cans has tight-fitting lids. Dishwasher is used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 32 degrees Fahrenheit and Freezer was measures at -11 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 77 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPA observed medications are labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 05/17/2023 02:01 PM - It Cannot Be Edited

Created By: Chinwe Nwogene On 05/17/2023 at 01:35 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A HOME 4 WAYNE, INC.	FACILITY NUMBER: 331880742
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having a written medical assessment documentation for resident #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	James stated a proof of the resident #2 written medical assessment will be provided to LPA by the POC due date 5/26/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Chinwe Nwogene

LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A HOME 4 WAYNE, INC.	FACILITY NUMBER: 331880742
	VISIT DATE: 05/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809.

Bathroom; LPA toured two #2 out of #2 residents bathroom and observed bathroom to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 117 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPA tour the garage and observed garage to be clean.

Laundry; LPA observed laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for approved capacity. Cleaning supplies are stored away in the laundry room, inaccessible to clients.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Refrigerator is large enough to accommodate required perishables.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Two #2 staff and #2 residents' records were reviewed, one #1 resident has no medical assessment documentation on file (A citation will be issued). All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The Administrator Certificate expires on 5/25/2023. James stated the Administrator, Pamela Watson already mailed the recertification packet to the department.

Interview; Two #2 staff and one #1 resident present were interviewed.

Therefore, based on the observations made during today’s visit, one #1 citation will be issued per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to James Willis.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3